o&g update course 2012 hospital segamat

1. Diabetes in Pregnancy
Dr. Ab Rahim B Abd Ghani
HPSF MUAR

2. Overview
1. Introduction
2. Definition
3. Screening
4. Management
5. Complications/Outcomes

3. Introduction
• Diabetes in pregnant women is associated
with an increased risk for maternal and
neonatal morbidities and remains a
significant medical challenge.
• 650,000 births in England & Wales per year
• 2-5% women have diabetes
• 87% diabetic pregnancies due to gestational
diabetes

4. Introduction
• Prevalence diabetes is increasing
• Early diagnosis of gestational diabetes is an
important step to improve outcomes and
systematic or selective screening with the
OGTT should be established
• Perinatal mortality remains 5x higher
• Congenital malformations up to 10x more
common

5. Diabetes in Pregnancy
• Gestational Diabetes Mellitus (88%)
• Type 1 Diabetes Mellitus (4%)
• Type 2 Diabetes Mellitus (8%)

6. Definition
• ‘carbohydrate intolerance resulting in
hyperglycemia of variable severity with
onset or first recognition during pregnancy’
World health Organization, 1999

7. Statistics- Prevalence of GDM in
Malaysia
•N Idris et al -prevalence of GDM –18.3%
•Peng Chiong Tan, prevalence of GDM
-11.4%
•Nurain et al, prevalence of GDM – 16.1%

8. SCREENING

9. • Controversial
• Aim – early diagnosis is important to improve
outcomes
• Universal screening is recommended, but
currently using selective screening base on risk
factors
• Would vary according to
– Population
– (eg:asians>whites)
– Timing
– (high risk?average risk?low risk?)
– Screening tests-50 g
– Criteria used for diagnosis- WHO, ADA

10. Screening-Suggested (NICE
guideline 2008)
• Screening for gestational diabetes using risk
factors at the booking appointment
• Early self-monitoring of blood glucose or a 2-
hour 75 g oral glucose tolerance test (OGTT) at
16–18 weeks to test for gestational diabetes if the
woman has had gestational diabetes previously.
• Followed by OGTT at 28 weeks if the first test is
normal
• An OGTT to test for gestational diabetes at 24–28
weeks if the woman has any other risk factors.

11. Who should be screened
Clinical characteristics including
• Obesity
• Symptoms (polyuria, polydipsia)
• Personal history
• Glucosuria
• Family history
• Previous big baby
• Polyhydramnios
• Previous unexplained stillbirths/neonatal death
• History of recurrent vaginal candidiasis

13. Detecting diabetes
World Health Organization
American Diabetic Association
etc

14. Overt Diabetes

15. GDM
using 75 g OGTT

16. The MGTT
• 75 g Load of glucose in flavoured drink
given
• Fasting levels < 5.6 mmol/L
• Post drink 2 hours < 7.8 mmol/L

17. Blood Sugar Profile- WHO

18. Pre or Post Prandial

20. Blood Sugar Profile- Suggested
Timing and Values
Pre
breakfast/Fasting
6
2 hrs post
Breakfast
7
2 hrs post Lunch 7
2 hrs post Dinner 7

21. FETAL & PERINATAL COMPLICATIONS
Embryo
Fetus
Newborn
Abortions
Malformations
Growth
alterations
macrosomia
IUGR
Dystocia
Perinatal asphyxia
Metabolic alterations
Hypoglycaemia
Hypocalcaemia
Hyperbilirubinemia
Polycythaemia
Alterations of lung
maturity
Respiratory distress
syndrome
Sudden
Intrauterine
demise

22. MATERNAL
COMPLICATIONS
Hypertension
Preterm
labor
Infections
Urinary
Vaginal
Vascular
Retina
Renal
Cardiac
Hyper/hypoglycaemia
Acidosis
Coma
Polyhydramnios
Increased operative delivery and
birth trauma

23. Management
• Pre pregnancy Counseling
• Antenatal
• Intrapartum
• Postpartum

24. Pre pregnancy Counseling
General guidelines:
•Pregnancy is planned,
•Explain risks of congenital anomalies and
spontaneous abortions – depends on glucose control
•Information on chronic complications and potential
impact on pregnancy and effect of pregnancy on
chronic complications
•Fitness for pregnancy –retinopathy, nephropathy,
HPT, neuropathy and IHD

25. Pre pregnancy counseling
• Physical examination –BP, eye
examination, renal status, cardiac status,
neurological assessment
• Laboratory evaluation –HbA1c, renal
function, 24h urine creatinine clearance,
protein, Urine C&S
• Optimize Glycaemic control- Combine
care/dietitian. Against preg if HbA1c >10
• Start on Folic acid 5mg od.

26. Antenatal Management
Before or as soon as pregnancy is confirmed:
• Stop oral hypoglycaemic agents, apart from
metformin, and commence insulin if required
• Stop angiotensin-converting enzyme inhibitors
and angiotensin-II receptor antagonists and
consider alternative antihypertensives
• Stop statins.

27. Antenatal Management
• Dating Ultra sound first trimester
• Refer to Booking to Hospital with specialist
• Refer to Dietitian
• Consider Starting Insulin if target blood
glucose not achieve after 1-2 weeks on diet.
• Screen for Diabetic Retinopathy and
Nephropathy especially established Diab
early or at 28 weeks

28. Antenatal Management
• Antenatal examination of the four-chamber view
of the fetal heart and outflow tracts at 18–20
weeks
• Ultrasound monitoring of fetal growth and
amniotic fluid volume every 4 weeks from 28 to
36 weeks
• individualised monitoring of fetal wellbeing to
women at risk of intrauterine growth restriction
(those with macrovascular disease or
nephropathy).

29. Antenatal Management
• Not to allow post date in GDM on diet
control
• Deliver at 38 weeks if on Insulin Therapy
• To discuss mode and timing of delivery
based on assessment of glycaemic control,
insulin dosing and estimation of fetal
weight.

30. Outcomes of a diabetic
pregnancy to the fetus
EARLY PREGNANCY
• If glycemic control poor within first 8
weeks/ HbA1c >9.5% there is an increased
risk of spontaneous miscarriages and major
malformations
• Target Hb A1c 6.1%

31. Congenital malformations
• High maternal
glucose is toxic to the
early embryo – Risk
rises with worsening
glycaemic control at
conception and in early
first trimester
• Esp renal, cardiac
and central nervous
system abnormalities

32. Caudal regression syndrome
(sacral agenesis)
• The overall incidence: 1 in
7,500 live births.
• About 1 in 6 of patients is the
child of a diabetic mother.
• The risk for a child of a
diabetic mother of acquiring
the syndrome is 1%.

33. LATER IN THE PREGNANCY
• Incidence of abnormal fetal heart rate, low
Apgar scores is increased
• Higher risk of fetal asphyxia and distress
• Higher risk of stillbirths (d/t the chronic
fetal hypoxia)

34. Fetal macrosomia
• Hallmark of diabetic pregnancy
• High placental transfer of glucose leads to
hyperplasia of foetal pancreas and foetal
hyperinsulinaemia
• Insulin is the main growth hormone for the
foetus – hence macrosomia
• Brain growth is spared
• AC measured serially is the best
measurement for macrosomic fetuses

35. • Much of the excess weight
is truncal fat, hence
shoulder dystocia
• Macrosomia occurs in
25% of infants of type 1
diabetic mothers
• Excessive insulin secretion
persists after birth, →
hypoglycaemia
• Hyperglycaemia is the
main causative factor in
delayed lung maturation

36. Shoulder Dystocia with brachial plexus injury
9% when BW < 4 kg
26% when BW > 4.5kg
5-10% of infants have permanent brachial
plexus injuries.
Consider delivery by LSCS if suspected fetal
Macrosomia
Most likely due to poor Glycemic control
especially post pandial.

37. Hypoglycemia
• Most common cause of neonatal morbidity in
infants of diabetic mothers
• Maternal control during pregnancy and labour and
delivery will influence the degree of
hypoglycemia
• Neonatal hypoglycemia is usually asymptomatic
• Routine blood sugar monitoring is recommended
• A level of 2.6 mmol/L or above is generally
accepted

38. Established Diabetes
1 – 2% of the pregnant population.
Higher risk for Maternal complication with high
perinatal morbidity and mortality.
Effects of pregnancy of DM
• Insulin requirements increases during pregnancy
• Retinopathy aggravated
• Those with nephropathy more likely to have pre
eclampsia
• High risk of preterm delivery and asymmetrical
SGA
• Combine care important.

39. Summary of Management
Pre Pregnancy Planning necessary for good control
Switch from OHA to insulin
Women should be taught to monitor their own glucose
levels
HbA1c should be checked at booking
Pregnancy Aim to maintain normoglycemia
Antenatal follow ups should monitor blood pressure, look
for s/s of infection, fetal growth monitored by clinical
means as well as ultrasound
Delivery Aim for spontaneous delivery however usually induction
done at 38 weeks. If on diet control at EDD.
IV insulin and IV glucose (DIK) regime during labour
Beware of shoulder dystocia

40. Management
• Key to successful management is early diagnosis
• Early treatment
• Maintain good Glycemic control
• Early ultrasounds to exclude fetal abnormalities
• Attempt diet control (unless patient already
established diabetic)
• Followed by insulin if not controlled by diet
• Oral hypoglycemics should be avoided as risk of
teratogenicity in early pregnancy unless poorly
control despite high dose insulin.

41. Medication
• Metformin may be used before and during
pregnancy, Reserve for poorly control on high
dose insulin.
• Data from clinical trials and other sources do not
suggest that the rapid-acting insulin analogues
(aspart and lispro) adversely affect pregnancy or
the health of the fetus or newborn baby.
• Evidence about the use of long-acting insulin
analogues during pregnancy is limited. Isophane
insulin is the first-choice long-acting insulin
during pregnancy.

42. Delivery
• Timing of delivery depends on control
• If on insulin, the pregnancy is best terminated by
38 weeks
• If diet control is adequate then the pregnancy may
be prolonged to term
• Mode of delivery depends on clinical judgement
• Diabetes itself is not an indication for caesarean
• Factors favoring an elective CS are
– Macrosomia
– Suspicion of cephalopelvic disproportion
– Malpresentation
– polyhydramnious

43. During Labour:
• DIK regime used
• Infusion of 500ml of 10% Dextrose with 1 g
KCL to which an appropriate dose of
insulin added.
• Dose of insulin should be titrated
accordingly to hourly GM
• Adequate pain relief
• Continuous CTG
• Trained birth attendant

44. Postpartum
• Monitor for hypoglycemia/hyperglycemia
• Requirement of insulin halved post partum
• Consider restart back on OHA once taking normal
diet
• Advice breast feeding
• Schedule appointment for review of diabetes and
repeat MOGTT at 6/52
• Contraception advice, Life style modification

45. References
• World Health Organization Prevention of diabetes
mellitus. Geneva, World Health Org., 1994 .
• American Diabetic Association
• Australasian Diabetes in Pregnancy Society.
http://www.adips.org/
• Malaysian Clinical practice guidelines for management of
Type II Diabetes Mellitus. 4th
Edition. 2009
• Diabetes in Pregnancy. NICE. March 2008

46. THANK YOU